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Reeves JJ, Broderick RC, Lee AM, Blitzer RR, Waterman RS, Cheverie JN, Jacobsen GR, Sandler BJ, Bouvet M, Doucet J, Murphy JD, Horgan S. The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy. Surgery 2022; 171:1168-1176. [PMID: 34952715 DOI: 10.1016/j.surg.2021.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/18/2021] [Accepted: 09/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease. METHODS A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year. RESULTS The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year. CONCLUSION The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.
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Affiliation(s)
- J Jeffery Reeves
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA.
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Arielle M Lee
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Rachel R Blitzer
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Ruth S Waterman
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA
| | - Joslin N Cheverie
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Michael Bouvet
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Jay Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
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Singhirunnusorn J, Niyomsri S, Dilokthornsakul P. The cost-effectiveness analysis of laparoscopic hepatectomy compared with open liver resection in the early stage of hepatocellular carcinoma: a decision-analysis model in Thailand. HPB (Oxford) 2022; 24:183-191. [PMID: 34238678 DOI: 10.1016/j.hpb.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 05/27/2021] [Accepted: 06/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic liver resection is increasing operate. In the early stage of hepatocellular carcinoma (HCC), many studies supported that laparoscopic liver resection was a safe procedure and showed some clinical benefits. However, the full economic evaluation has not been fully investigated. METHODS A hybrid model of decision tree and Markov state transition model was constructed. Health outcomes were life-year gained (LYs), and quality-adjusted life years (QALYs). A deterministic sensitivity analysis was performed and a probabilistic sensitivity analysis was conducted by 1,000 micro-simulation. The incremental cost-effectiveness ratio (ICER) was reported and the willingness to pay (WTP) was defined at 160,000 THB per QALY gained. RESULTS Laparoscopic liver resection in the early stage of HCC was not cost-effective. In the base-case analysis, the total lifetime cost of laparoscopic approach was an average of 413,377 THB (US$13,214) higher than open approach by 55,474 THB (US$1,773) with a small QALY gained. The resulting ICER was 1,356,521 THB (US$43,362) per QALY gained. CONCLUSION Laparoscopic liver resection is not considered as a cost-effective alternative to open liver surgery in the early stage of HCC. In the Thai healthcare perspective, the results from this study may inform policymakers for the future policy implementation and healthcare resource allocation.
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Affiliation(s)
- Jumpol Singhirunnusorn
- National Cancer Institute of Thailand, Department of Medical Services, Ministry of Public Health, Bangkok, Thailand
| | - Siwaporn Niyomsri
- National Cancer Institute of Thailand, Department of Medical Services, Ministry of Public Health, Bangkok, Thailand.
| | - Piyameth Dilokthornsakul
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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Bagepally BS, Sajith Kumar S, Natarajan M, Sasidharan A. Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000779. [PMID: 35064024 PMCID: PMC8785172 DOI: 10.1136/bmjgast-2021-000779] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/17/2021] [Indexed: 11/04/2022] Open
Abstract
IntroductionCholecystectomy is a standard treatment in the management of symptomatic gallstone disease. Current literature has contradicting views on the cost-effectiveness of different cholecystectomy treatments. We have conducted a systematic reappraisal of literature concerning the cost-effectiveness of cholecystectomy in management of gallstone disease.MethodsWe systematically searched for economic evaluation studies from PubMed, Embase and Scopus for eligible studies from inception up to July 2020. We pooled the incremental net benefit (INB) with a 95% CI using a random-effects model. We assessed the heterogeneity using the Cochrane-Q test, I2 statistic. We have used the modified economic evaluation bias (ECOBIAS) checklist for quality assessment of the selected studies. We assessed the possibility of publication bias using a funnel plot and Egger’s test.ResultsWe have selected 28 studies for systematic review from a search that retrieved 8710 studies. Among them, seven studies were eligible for meta-analysis, all from high-income countries (HIC). Studies mainly reported comparisons between surgical treatments, but non-surgical gallstone disease management studies were limited. The early laparoscopic cholecystectomy (ELC) was significantly more cost-effective compared with the delayed laparoscopic cholecystectomy (DLC) with an INB of US$1221 (US$187 to US$2255) but with high heterogeneity (I2=73.32%). The subgroup and sensitivity analysis also supported that ELC is the most cost-effective option for managing gallstone disease or cholecystitis.ConclusionELC is more cost-effective than DLC in the treatment of gallstone disease or cholecystitis in HICs. There was insufficient literature on comparison with other treatment options, such as conservative management and limited evidence from other economies.PROSPERO registration numberCRD42020194052.
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Affiliation(s)
| | - S Sajith Kumar
- Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, India
| | - Meenakumari Natarajan
- Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, India
| | - Akhil Sasidharan
- Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, India
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Bedada AG, Hsiao M, Azzie G. Sustaining a laparoscopic program in resource-limited environments: results and lessons learned over 13 years in Botswana. Surg Endosc 2020; 35:3716-3722. [PMID: 32748266 DOI: 10.1007/s00464-020-07854-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Metrics of sustainability and frank descriptions of the unique challenges, successes, failures, and lessons learned from a longitudinal laparoscopic program in resource-limited environments are lacking. We set out to evaluate the safety and sustainability of the laparoscopic cholecystectomy program at Princess Marina Hospital, the largest tertiary and teaching hospital in Botswana. METHODS We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy from January 2013 to December 2018. Technical independence and sustainability factors were measured and discussed. RESULTS Two hundred and twenty-six laparoscopic cholecystectomies (LC) and 39 open cholecystectomies (OC) were performed. Four surgeons who trained as part of the inaugural laparoscopic program performed 48.2% of LC. Eleven surgeons who trained elsewhere performed the remainder. Overall, 94.2% of LC were performed without expatriate surgeons. The conversion rate was 25/226 (11.1%). There were 3 bile duct injuries in the LC group (3/226, 1.3%) and none in the OC group. There was one mortality in the OC group (1/39, 2.6%) and none in the LC group. Fostering a trusting relationship among all stakeholder was identified as the major key to success, while the development of a system-based strategy was identified as the most significant ongoing challenge. CONCLUSION The laparoscopic cholecystectomy program in Botswana initially established between 2006 and 2012 has moved into its sustainability phase, characterized by increased usage of laparoscopy and greater independent operating by local surgeons, all while maintaining patient safety. Sustaining a laparoscopic program in resource-limited environments has particular challenges which may differ from country to country.
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Affiliation(s)
- Alemayehu Ginbo Bedada
- Department of Surgery, Faculty of Medicine, Princess Marina Hospital, University of Botswana, River Walk, Village, PO Box 45759, Gaborone, Botswana.
| | - Marvin Hsiao
- Division of General Surgery, Royal Columbian Hospital, Vancouver, BC, Canada
| | - Georges Azzie
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada
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Establishing a Sustainable Training Program for Laparoscopy in Resource-Limited Settings: Experience in Ghana. Ann Glob Health 2020; 86:89. [PMID: 32775220 PMCID: PMC7394194 DOI: 10.5334/aogh.2957] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Healthcare equipment funded by international partners is often not properly utilized in many developing countries due to low levels of awareness and a lack of expertise. A long-term on-site training program for laparoscopic surgery was established at a regional hospital in Ghana upon request of the Ghana Health Service and local surgeons. Objective The authors report the initial 32-month experience of implementing laparoscopic surgery focusing on the trainees' response, technical independence, and factors associated with the successful implementation of a "new" surgical practice. Methods Curricular structure and feedback results of the trainings for doctors and nurses, and characteristics of laparoscopic procedures performed at the Greater Accra Regional Hospital between January 2017 and September 2019 were retrospectively reviewed. Findings Comprehensive training including two weeks of simulation workshops followed by animal labs were regularly provided for the doctors. Among the 97 trainees, 27.9% had prior exposure in laparoscopic surgery, 95% were satisfied with the program. Eleven nurses attained professional competency over 15 training sessions where none had prior exposure to laparoscopic surgery. Since the first laparoscopic cholecystectomy in February 2017, 82 laparoscopic procedures were performed. The scope of the surgery was expanded from general surgery (n = 46) to gynecology (n = 33), pediatric surgery (n = 2), and urology (n = 1). The volume of local doctors as primary operators increased from 0% (0/17, February to December 2017) to 41.9% (13/31, January to October 2018) and 79.4% (27/34, November 2018 to September 2019), with 72.5% of the cases being assisted by the expatriate surgeon. There were no open conversions, technical complications, or mortalities. Local doctors independently commenced endoscopic surgical procedures including cystoscopies, hysteroscopies, endoscopic neurosurgeries and arthroscopies. Conclusion Sensitization and motivation of the surgical workforce through long-term continuous on-site training resulted in the successful implementation of laparoscopic surgery with a high level of technical independence.
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Abstract
Laparoscopy has numerous clinical benefits compared to laparotomy. However, a functional laparoscopy program requires significant investment and, as a result, remains unavailable for the majority of the world’s population in low- and middle-income countries. The effort to bring laparoscopy to low-resource settings has produced variable outcomes resulting from the challenges inherent to a complex surgical program. This paper highlights these shortcomings and identifies opportunities to improve future laparoscopy programs.
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Barriers to adoption of laparoscopic cholecystectomy in a county hospital in Guatemala. Surg Endosc 2019; 33:4128-4132. [DOI: 10.1007/s00464-019-06720-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 02/20/2019] [Indexed: 12/15/2022]
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Tran BX, Tran TD, Nathan N, Ngo CQ, Nguyen LT, Nguyen LH, Nguyen HLT, Nguyen CT, Do HP, Nguyen THT, Tran TT, Thai TPT, Dang AK, Nguyen NB, Latkin CA, Ho CSH, Ho RCM. Catastrophic health expenditure of Vietnamese patients with gallstone diseases - a case for health insurance policy revaluation. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:151-158. [PMID: 30804677 PMCID: PMC6375106 DOI: 10.2147/ceor.s191379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose Despite gallstone diseases (GSDs) being a major public health concern with both acute and chronic episodes, none of the studies in Vietnam has been conducted to investigate the household expenditure for the GSD treatment. The objective of this study was to estimate the costs of managing GSD and to explore the prevalence and determinants of catastrophic health expenditure (CHE) among Vietnamese patients. Materials and methods A cross-sectional study was conducted from June 2016 to March 2017 in the Department of Hepatobiliary and Pancreatic Surgery, Viet Duc Hospital in Hanoi, Vietnam. A total of 206 patients were enrolled. Demographic and socioeconomic data, household income, and direct and indirect medical costs of patients seeking treatment for GSD were collected through face-to-face interview. Multivariate logistic regression was used to explore factors associated with CHE. Results The prevalence of CHE in patients suffering from GSD was 35%. The percentage of patients who were covered by health insurance and at risk for CHE was 41.2%, significantly higher than that of those noninsured (15.8%). Proportions of patients with and without health insurance who sought outpatient treatment were 30.6% and 81.6%, respectively. Patients who were divorced or widowed and had intrahepatic gallstones were significantly more likely to experience CHE. Those who were outpatients, were women, had history of pharmacological treatment to parasitic infection, and belong to middle and highest monthly household income quantile were significantly less likely to experience CHE. Conclusion The findings suggested that efforts to re-evaluate health insurance reimbursement capacity, especially for acute diseases and taking into account the varying preferences of people with different disease severity, should be conducted by health authority. Further studies concerning CHE of GSD in the context of ongoing health policy reform should consider utilizing WHO-recommended measures like the fairness in financial contribution index, as well as taking into consideration the behavioral aspects of health care spending.
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Affiliation(s)
- Bach Xuan Tran
- Department of Health Economics, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.,Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Tho Dinh Tran
- Department of Hepatobiliary Surgery, Vietnam-Germany Hospital, Hanoi, Vietnam
| | - Nila Nathan
- University of California, Santa Barbara, Santa Barbara, CA, USA
| | - Chau Quy Ngo
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Loi Thi Nguyen
- Woolcock Institute of Medical Research Vietnam, Hanoi, Vietnam
| | - Long Hoang Nguyen
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | | | - Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Danang, Vietnam,
| | - Huyen Phuc Do
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Trang Huyen Thi Nguyen
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Tung Thanh Tran
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Thao Phuong Thi Thai
- Department of General Planning, Friendship Hospital, Hanoi, Vietnam.,Department of Cardiology, Friendship Hospital, Hanoi, Vietnam
| | - Anh Kim Dang
- Institute for Global Health Innovations, Duy Tan University, Danang, Vietnam,
| | - Nam Ba Nguyen
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Carl A Latkin
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Cyrus S H Ho
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Roger C M Ho
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam.,Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Imran JB, Ochoa-Hernandez A, Herrejon J, Madni TD, Clark AT, Huerta S. Surgical approach to gallbladder disease in rural Guatemala. J Surg Res 2017; 218:329-333. [DOI: 10.1016/j.jss.2017.06.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/15/2017] [Accepted: 06/19/2017] [Indexed: 12/15/2022]
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Laparoscopic Versus Open Cholecystectomy: A Cost-Effectiveness Analysis at Rwanda Military Hospital. World J Surg 2017; 41:1225-1233. [PMID: 27905020 DOI: 10.1007/s00268-016-3851-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries. Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings. METHODS A cost-effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were performed to determine the robustness of the results. RESULTS The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost-effectiveness ratio for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay (WTP) thresholds greater than $3975/QALY. CONCLUSIONS At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to combat these barriers and provide laparoscopic surgery.
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Sutton AJ, Vohra RS, Hollyman M, Marriott PJ, Buja A, Alderson D, Pasquali S, Griffiths EA. Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology. Br J Surg 2016; 104:98-107. [PMID: 27762448 DOI: 10.1002/bjs.10317] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/29/2016] [Accepted: 08/15/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a 'delayed' operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease. METHODS Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost-utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model. RESULTS Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0-120 000). CONCLUSION Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs.
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Affiliation(s)
- A J Sutton
- Health Economics Unit, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,National Institute for Health Research Diagnostic Evidence Co-operative Leeds, Leeds, UK
| | - R S Vohra
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - M Hollyman
- West Midlands Surgical Research Collaborative, Birmingham, UK
| | - P J Marriott
- West Midlands Surgical Research Collaborative, Birmingham, UK.,Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - A Buja
- Laboratory of Public Health and Population Studies, Department of Molecular Medicine, University of Padua
| | - D Alderson
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - S Pasquali
- Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - E A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
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12
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Establishing a contextually appropriate laparoscopic program in resource-restricted environments: experience in Botswana. Ann Surg 2015; 261:807-11. [PMID: 24915782 DOI: 10.1097/sla.0000000000000691] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Differences in opinion exist as to the feasibility of establishing sustainable laparoscopic programs in resource-restricted environments. At the request of local surgeons and the Ministry of Health in Botswana, a training program was established to assist local colleagues with laparoscopic surgery. We reviewed our multifaceted and evolving international collaboration and highlighted those factors that have helped or hindered this program. METHODS From 2006 to 2012, a training program consisting of didactic teaching, telesimulation, Fundamentals of Laparoscopic Surgery certification, yearly workshops, and ongoing mentorship was established. We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy, and measured the indicators of technical independence and program sustainability. RESULTS Twelve surgeons participated in the training program and performed 270 of 288 laparoscopic cholecystectomies. Ninety-six open cases were performed by these and 5 additional surgeons. Fifteen laparoscopic cases were converted (5.2%). The median postoperative length of hospital stay was significantly shorter in the laparoscopic group than in the open group (1 day vs 7 days, P < 0.001). As the training program progressed, the proportion of laparoscopic cases completed without an expatriate surgeon present increased significantly (P = 0.001). CONCLUSIONS A contextually appropriate long-term partnership may assist with laparoscopic upskilling of colleagues in low- and middle-income countries. This type of collaboration promotes local ownership and may translate into better patient outcomes associated with laparoscopic surgery. In resource-restricted environments, the factors threatening sustainability may differ from those in high-income countries and should be identified and addressed.
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13
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Chao TE, Mandigo M, Opoku-Anane J, Maine R. Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies. Surg Endosc 2015; 30:1-10. [PMID: 25875087 DOI: 10.1007/s00464-015-4201-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 03/31/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopy may prove feasible to address surgical needs in limited-resource settings. However, no aggregate data exist regarding the role of laparoscopy in low- and middle-income countries (LMICs). This study was designed to describe the issues facing laparoscopy in LMICs and to aggregate reported solutions. METHODS A search was conducted using Medline, African Index Medicus, the Directory of Open Access Journals, and the LILACS/BIREME/SCIELO database. Included studies were in English, published after 1992, and reported safety, cost, or outcomes of laparoscopy in LMICs. Studies pertaining to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cystoscopy, computer-assisted surgery, pediatrics, transplantation, and bariatrics were excluded. Qualitative synthesis was performed by extracting results that fell into three categories: advantages of, challenges to, and adaptations made to implement laparoscopy in LMICs. PRISMA guidelines for systematic reviews were followed. RESULTS A total of 1101 abstracts were reviewed, and 58 articles were included describing laparoscopy in 25 LMICs. Laparoscopy is particularly advantageous in LMICs, where there is often poor sanitation, limited diagnostic imaging, fewer hospital beds, higher rates of hemorrhage, rising rates of trauma, and single income households. Lack of trained personnel and equipment were frequently cited challenges. Adaptive strategies included mechanical insufflation with room air, syringe suction, homemade endoloops, hand-assisted techniques, extracorporeal knot tying, innovative use of cheaper instruments, and reuse of disposable instruments. Inexpensive laboratory-based trainers and telemedicine are effective for training. CONCLUSIONS LMICs face many surgical challenges that require innovation. Laparoscopic surgery may be safe, effective, feasible, and cost-effective in LMICs, although it often remains limited in its accessibility, acceptability, and quality. This study may not capture articles written in languages other than English or in journals not indexed by the included databases. Surgeons, policymakers, and manufacturers should focus on plans for sustainability, training and retention of providers, and regulation of efforts to develop laparoscopy in LMICs.
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Affiliation(s)
- Tiffany E Chao
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB 425, Boston, MA, 02114, USA. .,Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
| | - Morgan Mandigo
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jessica Opoku-Anane
- Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Rebecca Maine
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Shen HJ, Hsu CT, Tung TH. Economic and medical benefits of ultrasound screenings for gallstone disease. World J Gastroenterol 2015; 21:3337-3343. [PMID: 25805942 PMCID: PMC4363765 DOI: 10.3748/wjg.v21.i11.3337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/03/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether screening for gallstone disease was economically feasible and clinically effective.
METHODS: This clinical study was initially conducted in 2002 in Taipei, Taiwan. The study cohort total included 2386 healthy adults who were voluntarily admitted to a regional teaching hospital for a physical check-up. Annual follow-up screening with ultrasound sonography for gallstone disease continued until December 31, 2007. A decision analysis using the Markov Decision Model was constructed to compare different screening regimes for gallstone disease. The economic evaluation included estimates of both the cost-effectiveness and cost-utility of screening for gallstone disease.
RESULTS: Direct costs included the cost of screening, regular clinical fees, laparoscopic cholecystectomy, and hospitalization. Indirect costs represent the loss of productivity attributable to the patient’s disease state, and were estimated using the gross domestic product for 2011 in Taiwan. Longer time intervals in screening for gallstone disease were associated with the reduced efficacy and utility of screening and with increased cost. The cost per life-year gained (average cost-effectiveness ratio) for annual screening, biennial screening, 3-year screening, 4-year screening, 5-year screening, and no-screening was new Taiwan dollars (NTD) 39076, NTD 58059, NTD 72168, NTD 104488, NTD 126941, and NTD 197473, respectively (P < 0.05). The cost per quality-adjusted life-year gained by annual screening was NTD 40725; biennial screening, NTD 64868; 3-year screening, NTD 84532; 4-year screening, NTD 110962; 5-year screening, NTD 142053; and for the control group, NTD 202979 (P < 0.05). The threshold values indicated that the ultrasound sonography screening programs were highly sensitive to screening costs in a plausible range.
CONCLUSION: Routine screening regime for gallstone disease is both medically and economically valuable. Annual screening for gallstone disease should be recommended.
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Lilford RJ, Burn SL, Diaconu KD, Lilford P, Chilton PJ, Bion V, Cummins C, Manaseki-Holland S. An approach to prioritization of medical devices in low-income countries: an example based on the Republic of South Sudan. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2015; 13:2. [PMID: 25606027 PMCID: PMC4298960 DOI: 10.1186/s12962-014-0027-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 12/15/2014] [Indexed: 11/10/2022] Open
Abstract
Background Efficient and evidence-based medical device and equipment prioritization is of particular importance in low-income countries due to constraints in financing capacity, physical infrastructure and human resource capabilities. Methods This paper outlines a medical device prioritization method developed in first instance for the Republic of South Sudan. The simple algorithm offered here is a starting point for procurement and selection of medical devices and can be regarded as a screening test for those that require more labour intensive health economic modelling. Conclusions A heuristic method, such as the one presented here, is appropriate for reaching many medical device prioritization decisions in low-income settings. Further investment and purchasing decisions that cannot be reached so simply require more complex health economic modelling approaches. Electronic supplementary material The online version of this article (doi:10.1186/s12962-014-0027-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard J Lilford
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, College of Dental and Medical Sciences, University of Birmingham, Edgbaston, West Midlands, B15 2TT UK ; Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, CV4 7AL UK
| | - Samantha L Burn
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, College of Dental and Medical Sciences, University of Birmingham, Edgbaston, West Midlands, B15 2TT UK
| | - Karin D Diaconu
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, College of Dental and Medical Sciences, University of Birmingham, Edgbaston, West Midlands, B15 2TT UK
| | - Peter Lilford
- Ministry of Finance, Government of South Sudan, Juba, South Sudan
| | - Peter J Chilton
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, College of Dental and Medical Sciences, University of Birmingham, Edgbaston, West Midlands, B15 2TT UK
| | - Victoria Bion
- School of Medicine, University of Southampton, Southampton, SO17 1BJ UK
| | - Carole Cummins
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, College of Dental and Medical Sciences, University of Birmingham, Edgbaston, West Midlands, B15 2TT UK
| | - Semira Manaseki-Holland
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, College of Dental and Medical Sciences, University of Birmingham, Edgbaston, West Midlands, B15 2TT UK
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Acute cholecystitis: WSES position statement. World J Emerg Surg 2014; 9:58. [PMID: 25422672 PMCID: PMC4242474 DOI: 10.1186/1749-7922-9-58] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 09/29/2014] [Indexed: 12/16/2022] Open
Abstract
Background The management of acute calculous cholecystitis still offers room for debate in terms of diagnosis, severity scores, treatment options and timing for surgery. Material and methods A systematic review about the treatment of acute cholecystitis has been completed. The recommendations of recent guidelines have also been examined taking into account the results of the review. Results The evidence available in the literature supports the recommendation about laparoscopic cholecystectomy as treatment of choice for acute cholecystitis. Surgery should be performed as soon as possible after the diagnosis because early treatment reduces total hospital stay and does not increase complication or conversion rates. The antibiotics can play different roles and attention should be posed to the risk of emerging resistance. A surgical or percutaneous drainage of the gallbladder is advocated by some authors in the advanced forms of inflammation or patients with severe co-morbidities; however, the available evidence does not support it, and further studies are necessary to clarify its role.
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Leake PA, Pitzul K, Roberts PO, Plummer JM. Comparative analysis of open and laparoscopic colectomy for malignancy in a developing country. World J Gastrointest Surg 2013; 5:294-299. [PMID: 24520427 PMCID: PMC3920117 DOI: 10.4240/wjgs.v5.i11.294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/01/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the short-term, including oncologic, outcomes of open vs laparoscopic colectomy for cancer in a developing country.
METHODS: The records of patients who underwent elective open and laparoscopic colectomies for cancer at the University Hospital of the West Indies between January 2005 and December 2010 were retrospectively reviewed. Demographic (age, gender, Charlson comorbidity index score), peri-operative, post-operative and oncologic data were collected for each patient. Specific oncologic variables included lymph node yield, pathologic stage, grade, proximal, distal and circumferential margin involvement. Fisher’s exact, Mann-Whitney, and binary logistic regression tests were used for analysis. Significance level was set at P < 0.05.
RESULTS: There were 87 cases for open colectomy (OC) and 17 cases for laparoscopic colectomy (LC). Demographics did not significantly differ between OC and LC groups. Intra-operative blood loss and post-operative analgesic requirements did not significantly differ between groups. There was a trend towards longer operating times in OC group and shorter hospital stay in the LC group. Lymph node yield (14 vs 14, P = 0.619), proximal (10 cm vs 7 cm, P = 0.353) and distal (8 cm vs 8 cm, P = 0.57) resection margin distance and circumferential margin involvement (9 vs 0, P = 0.348) did not significantly differ between groups. Thirty-day morbidity was equivalent between groups (22 vs 6, P = 0.774). There were 6 deaths within 30 d of initial procedure, all in the OC group (6.9%).
CONCLUSION: Laparoscopic colectomy in a developing country is oncologically safe and represents a option for colonic malignancies in these regions. Such data encourage the continued laparoscopic development.
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Barriers to the uptake of laparoscopic surgery in a lower-middle-income country. Surg Endosc 2013; 27:4009-15. [DOI: 10.1007/s00464-013-3019-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 05/07/2013] [Indexed: 12/13/2022]
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Tongsiri S, Cairns J. Estimating population-based values for EQ-5D health states in Thailand. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:1142-5. [PMID: 22152185 DOI: 10.1016/j.jval.2011.06.005] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 05/09/2011] [Accepted: 06/09/2011] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To derive EuroQol five-dimensional (EQ-5D) health states values from the Thai general population. METHODS Forty-eight trained individuals successfully conducted interviews with a representative sample of 1409 respondents in 2007. A total of 12 sets of health states were used with one set allocated to each respondent. A respondent was requested to assign values for 11 states using the ranking and visual analogue scale methods and 10 states using the time trade-off method. The variables from the three existing models were used in model specifications and the best model was chosen on the basis of the extent of logical inconsistency in the estimated scores, predictive performance, parsimony, and sensitivity to changes in health. RESULTS Eighty-six health states were valued. The mean age of respondents was 44.6 years old. The highly consistent respondents tend to give higher scores for mild states and lower scores for severe states, compared with those given by the highly inconsistent respondents. The best model used variables from the Dolan 1997 study and estimated from the scores given by the respondents with fewer than 11 inconsistencies. The estimated scores are completely consistent, R(2) is 0.448. The second highest score was 0.766 given to state 11112 and the lowest score was -0.454 for state 33333. CONCLUSION Values for EQ-5D health states were estimated from the Thai general population. This is the first Thai generic health state value results to be used in evaluating health interventions in Thailand.
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Affiliation(s)
- Sirinart Tongsiri
- Faculty of Medicine, Mahasarakham University, Tambon Talad, Muang, Mahasarakham, Thailand.
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Wilson E, Gurusamy K, Gluud C, Davidson BR. Cost-utility and value-of-information analysis of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2010; 97:210-9. [PMID: 20035545 DOI: 10.1002/bjs.6872] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND : A recent systematic review found early laparoscopic cholecystectomy (ELC) to be safe and to shorten total hospital stay compared with delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis. The cost-effectiveness of ELC versus DLC for acute cholecystitis is unknown. METHODS : A decision tree model estimating and comparing costs to the UK National Health Service (NHS) and quality-adjusted life years (QALYs) gained following a policy of either ELC or DLC was developed with a time horizon of 1 year. Uncertainty was investigated with probabilistic sensitivity analysis, and value-of-information analysis estimated the likely return from further investment in research in this area. RESULTS : ELC is less costly (approximately - pound820 per patient) and results in better quality of life (+0.05 QALYs per patient) than DLC. Given a willingness-to-pay threshold of pound20 000 per QALY gained, there is a 70.9 per cent probability that ELC is cost effective compared with DLC. Full implementation of ELC could save the NHS pound8.5 million per annum. CONCLUSION : The results of this decision analytic modelling study suggest that on average ELC is less expensive and results in better quality of life than DLC. Future research should focus on quality-of-life measures alone.
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Affiliation(s)
- E Wilson
- Health Economics Group, Faculty of Health, University of East Anglia, Norwich, UK
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Manning RG, Aziz AQ. Should laparoscopic cholecystectomy be practiced in the developing world?: the experience of the first training program in Afghanistan. Ann Surg 2009; 249:794-8. [PMID: 19387323 DOI: 10.1097/sla.0b013e3181a3eaa9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We address the controversial issue of whether or not it is wise to perform and train laparoscopic cholecystectomy (LC) in a developing nation by reviewing the results of the first large series done in Afghanistan. Afghanistan has been devastated by 3 decades of war leaving it with deficiencies in training programs, medical technologies, and overall medical infrastructure that are among the worst in the developing world. METHODS We retrospectively reviewed 137 consecutive cholecystectomies, 102 laparoscopic and 35 open, performed by 4 senior and 3 junior surgeons trained at our hospital in Kabul from July 2005 until February 2008. Deaths, complications, conversion rate, operative time, and hospital length of stay were compared. RESULTS Unrecognized major operative injuries occurred in 4 LC patients, 3 bile leaks, and 1 duodenal perforation, although there were no such injuries in the open cholecystectomy group. Complication rates were much higher for patients operated on for acute cholecystitis for both surgeon groups. Even though junior surgeons converted to open cholecystectomy more frequently than senior surgeons, they had a higher major complication rate. Hospital length of stay was 28% shorter for the laparoscopic group. CONCLUSIONS The high rate of major unrecognized intraoperative complications during LC in our series underscores the difficulties inherent in performing and training LC in developing nations. Practical changes are suggested to make LC more efficient and safer in a developing world hospital.
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Affiliation(s)
- Richard G Manning
- Department of Surgery, CURE International Hospital, Kabul, Afghanistan.
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The greatest happiness of the greatest number? Policy actors' perspectives on the limits of economic evaluation as a tool for informing health care coverage decisions in Thailand. BMC Health Serv Res 2008; 8:197. [PMID: 18817579 PMCID: PMC2569929 DOI: 10.1186/1472-6963-8-197] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Accepted: 09/26/2008] [Indexed: 11/13/2022] Open
Abstract
Background This paper presents qualitative findings from an assessment of the acceptability of using economic evaluation among policy actors in Thailand. Using cost-utility data from two economic analyses a hypothetical case scenario was created in which policy actors had to choose between two competing interventions to include in a public health benefit package. The two competing interventions, laparoscopic cholecystectomy (LC) for gallbladder disease versus renal dialysis for chronic renal disease, were selected because they highlighted conflicting criteria influencing the allocation of healthcare resources. Methods Semi-structured interviews were conducted with 36 policy actors who play a major role in resource allocation decisions within the Thai healthcare system. These included 14 policy makers at the national level, five hospital directors, ten health professionals and seven academics. Results Twenty six out of 36 (72%) respondents were not convinced by the presentation of economic evaluation findings and chose not to support the inclusion of a proven cost-effective intervention (LC) in the benefit package due to ethical, institutional and political considerations. There were only six respondents, including three policy makers at national level, one hospital director, one health professional and one academic, (6/36, 17%) whose decisions were influenced by economic evaluation evidence. Conclusion This paper illustrates limitations of using economic evaluation information in decision making priorities of health care, perceived by different policy actors. It demonstrates that the concept of maximising health utility fails to recognise other important societal values in making health resource allocation decisions.
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Teerawattananon Y, Russell S. A difficult balancing act: policy actors' perspectives on using economic evaluation to inform health-care coverage decisions under the Universal Health Insurance Coverage scheme in Thailand. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11 Suppl 1:S52-S60. [PMID: 18387068 DOI: 10.1111/j.1524-4733.2008.00367.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES In Thailand, policymakers have come under increasing pressure to use economic evaluation to inform health-care resource allocation decisions, especially after the introduction of the Universal Health Insurance Coverage (UC) scheme. This article presents qualitative findings from research that assessed a range of policymakers' perspectives on the acceptability of using economic evaluation for the development of health-care benefit packages in Thailand. The policy analysis examined their opinions about existing decision-making processes for including health interventions in the UC benefit package, their understanding of health economic evaluation, and their attitudes, acceptance, and values relating to the use of the method. METHODS Semistructured interviews were conducted with 36 policy actors who play a major role or have some input into health resource allocation decisions within the Thai health-care system. These included 14 senior policymakers at the national level, 5 hospital directors, 10 health professionals, and 7 academics. RESULTS AND CONCLUSIONS Policy actors thought that economic evaluation information was relevant for decision-making because of the increasing need for rationing and more transparent criteria for making UC coverage decisions. Nevertheless, they raised several difficulties with using economic evaluation that would pose barriers to its introduction, including distrust in the method, conflicting philosophical positions and priorities compared to that of "health maximization," organizational allegiances, existing decision-making procedures that would be hard to change, and concerns about political pressure and acceptability.
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Affiliation(s)
- Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Thailand.
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Biscione FM. Reply to Chen et al. Infect Control Hosp Epidemiol 2008. [DOI: 10.1086/524912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hussain A, Mahmood HK, Dulku K. Laparoscopic cholecystectomy can be safely performed in a resource-limited setting: the first 49 laparoscopic cholecystectomies in Yemen. JSLS 2008; 12:71-6. [PMID: 18402743 PMCID: PMC3016033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the gold standard for gallstone disease. Many studies have confirmed the safety and feasibility of LC and have shown that it is comparable regarding complications to open cholecystectomy (OC). The aim of this study was to evaluate the outcomes of LC including safety, feasibility in a resource-poor setting like Yemen, and also to compare the outcomes of LC with those of OC. METHODS This was a prospective, nonrandomized, comparative study of 112 patients who were admitted to Alburaihy Hospital with a diagnosis of gallstone disease and underwent cholecystectomy from July 1998 to March 2004. Hospital stay, duration of operation, postoperative analgesia, and morbidity due to wound infection, bile leak, common bile duct (CBD) injury, missed CBD stone, bleeding, subphrenic abscess, and hernia were evaluated. Patients were followed up on an outpatient basis. RESULTS Forty-nine patients underwent LC and 63 patients underwent OC. The mean age of LC patients was 43.96 years and of OC patients was 44.63 years. The 2 groups were similar in terms of age (p=0.740) and sex (p=0.535). No significant difference was found in the incidence of acute cholecystitis between the 2 groups (p=0.000). The mean operative duration for LC was 39.88 minutes versus 56.76 minutes for OC (p=0.000), and the mean hospital stay was 1.63 and 5.38 days for LC and OC, respectively (p=0.000). A drain was used frequently in OC (p=0.000). LC patients needed less analgesia (p=0.000). The morbidity rate in LC was 12.2% versus 6.3% for OC, which was not statistically significant (p=0.394), (p>0.05). Wound infection and bile leak were more common with LC. No mortalities were reported in either group. CONCLUSION An experienced surgeon can perform LC safely and successfully in a resource-limited setting. As in other studies, LC outcomes were better than OC outcomes.
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Teerawattananon Y, Mugford M, Tangcharoensathien V. Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for end-stage renal disease: evidence for coverage decisions in Thailand. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2007; 10:61-72. [PMID: 17261117 DOI: 10.1111/j.1524-4733.2006.00145.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To examine the value for money of including peritoneal dialysis (PD) or hemodialysis (HD) into the universal health insurance scheme of Thailand. METHODS A probabilistic Markov model applied to end-stage renal disease (ESRD) patients aged 20 to 70 years was developed to examine the incremental cost-effectiveness ratio (ICER) of palliative care versus 1) providing PD as an initial treatment followed by HD if complications/switching occur; and 2) providing HD followed by PD if complications/switching occur. Input parameters were extracted from a national cohort, the Thailand Renal Replacement Therapy Registry, and systematic reviews, where possible. The study explored the effects of uncertainty around input parameters, presented as cost-effectiveness acceptability frontier, as well as the value of obtaining further information on chosen parameters, i.e., partial expected value of perfect information. RESULTS Using a societal perspective, the average ICER of initial treatment with PD and the average ICER of initial treatment with HD were 672,000 and 806,000 Baht per quality-adjusted life-year (QALY) gained (52,000 and 63,000 purchasing power parity [PPP] US$/QALY) compared with palliative care. Providing treatments for younger ESRD patients resulted in a significant improvement of survival and gain of QALYs compared with the older aged group. The cost-effectiveness and cost-utility ratios of both options for the older age group were relatively similar. CONCLUSIONS The results suggest that offering PD as initial treatment was a better choice than offering HD, but it would only be considered a cost-effective strategy if the social willingness-to-pay threshold was at or higher than 700,000 Baht per QALY (54,000 PPP US$/QALY) for the age 20 group and 750,000 Baht per QALY (58,000 PPP US$/QALY) for age 70 years.
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Teerawattananon K, Iewsakul S, Yenjitr C, Ausayakhun S, Yenjitr W, Mugford M, Teerawattananon Y. Economic evaluation of treatment administration strategies of ganciclovir for cytomegalovirus retinitis in HIV/AIDS patients in Thailand: a simulation study. PHARMACOECONOMICS 2007; 25:413-28. [PMID: 17488139 DOI: 10.2165/00019053-200725050-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND There are many effective interventions, via various routes (intravenous [IV], oral [OR], intravitreal injection [IVT] and intraocular implantation [IMP]), for treating cytomegalovirus retinitis (CMVR) that have become available. There are large variations in treating CMVR in clinical practice in Thailand. OBJECTIVE To evaluate the incremental cost-effectiveness ratio (ICER) of providing (i) IVT, (ii) IV/OR and (iii) IMP ganciclovir to patients with HIV/AIDS and CMVR versus providing no treatment. DESIGN A simulation study for which the input parameters were derived from a systematic review of the literature, a hospital-based survey and patient interviews. SETTING The analysis assumed a Thai healthcare system perspective. However, the model was run using both societal and healthcare provider perspectives. RESULTS Our results suggest that IVT ganciclovir was cost effective and the best option for treating patients with CMVR irrespective of whether patients received antiretroviral treatment (ART). In patients receiving ART, moving from IVT to IV/OR ganciclovir was also likely to be a cost-effective option. Offering IMP ganciclovir was not likely to be cost effective. Providing treatments for patients with bilateral CMVR was more cost effective than providing treatments for those with unilateral CMVR, and offering treatments for patients receiving ART was better value for money than treating patients without ART. CONCLUSIONS Our models suggest that IV/OR ganciclovir should be recommended for the treatment of unilateral and bilateral CMVR for patients receiving ART in the Thai healthcare system. IVT ganciclovir may also have a role in the treatment of CMVR patients not receiving ART.
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Teerawattananon Y, Russell S, Mugford M. A systematic review of economic evaluation literature in Thailand: are the data good enough to be used by policy-makers? PHARMACOECONOMICS 2007; 25:467-79. [PMID: 17523752 DOI: 10.2165/00019053-200725060-00003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In many countries, including Thailand, there is an increasing impetus to use economic evaluation to allow more explicit and transparent healthcare priority setting. However, an important question for policy makers in low- and middle-income countries is whether it is appropriate and feasible to introduce economic evaluation data into healthcare priority-setting decisions. In addition to ethical, social and political issues, information supply challenges need to be addressed. This paper systematically reviewed the literature on economic evaluation of health technology in Thailand published between 1982 and 2005. Its aim was to analyse the quantity, quality and targeting of economic evaluation studies that can provide a framework for those conducting similar reviews in other settings. The review revealed that, although the number of publications reporting economic evaluations has increased significantly in recent years, serious attention needs to be given to the quality of reporting and analysis. Furthermore, there is an absence of economic evaluation publications for 15 of the top 20 major health problems in Thailand, indicating a poor distribution of research resources towards the determination of cost-effective interventions for diminishing the disease burden of certain major health problems. If economic evaluation is only useful for policy makers when performed correctly and reported accurately, these findings depict information barriers to using economic evaluation to assist health decision-making processes in Thailand.
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Affiliation(s)
- Yot Teerawattananon
- International Health Policy Program, Ministry of Public Health, Nonthaburi 11000, Thailand.
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